Provider Demographics
NPI:1528004637
Name:VON SEGGERN, WESLEY P (DO)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:P
Last Name:VON SEGGERN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2332
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-2332
Mailing Address - Country:US
Mailing Address - Phone:616-975-1845
Mailing Address - Fax:616-975-1870
Practice Address - Street 1:1009 WEST GREEN STREET
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058
Practice Address - Country:US
Practice Address - Phone:269-948-3451
Practice Address - Fax:269-945-3588
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007600207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00359242OtherRAILROAD MEDICARE
MIP35450006Medicare PIN
MIE49405Medicare UPIN